‘Opening the door’ to employment in healthcare: People with lived experience of homelessness

Cover of a reportThe NIHR Policy Research Unit in Health and Social Care Workforce has published an evaluation of an access to employment programme in the NHS targeted at those with lived experience of homelessness. The pilot programme involved the homelessness charities Pathway and Groundswell and five NHS Trusts in England. Report author, Ian Kessler, here outlines the programme and the main findings of his evaluation.

Ian Kessler is Deputy Director of the NIHR Policy Research Unit in Health and Social Care Workforce. He is also Professor of Public Policy and Management at King’s Business School. (1,016 words)

Widening participation in the healthcare workforce has long been an important policy objective in the NHS. This has been reflected in an equalities, diversity, and inclusion agenda traditionally centring on gender and race, and more recently on young people with disabilities with the introduction of supported employment programmes by NHS Trusts, such as Project Search and Choice. However, the pursuit of widening participation is a rich policy space, connecting to an increasing range of workforce and broader service priorities.

Framed as ‘anchor institutions’, playing a key role as local employers, NHS Trusts have been encouraged to develop workforces which reflect, in socio-economic and demographic terms, the communities they serve. This role overlaps with moves to bring into the NHS workforce people with lived experience of various health conditions as a means of delivering patient-centred services and more effectively addressing health inequalities. Such moves have been especially evident in the introduction of the peer support worker role in mental health (which our Unit evaluated many years ago). More prosaically, but perhaps most pressing, the search for workforce diversity and inclusion addresses the recruitment and retention challenges faced by healthcare employers, with those at the margins of employment representing a new and reliable source of labour.

Facing multiple health and care challenges, and additional barriers to employment, people with lived experience of homelessness have to date been somewhat overlooked by the NHS workforce inclusion agenda. However, a recently completed NHSE (NHS England) pilot programme has sought to address this lacuna, seeking to facilitate access to employment in healthcare support worker (HCSW) roles amongst those with lived experience of homelessness (henceforth the ‘access to employment programme’). The findings from an evaluation of this pilot, undertaken by the NIHR Policy Research Unit in Health and Social Care Workforce, are set out in this recently published report. Tracking the pilot for over a year and based on around 30 interviews at national, regional and organisational level, the report brings to the fore how and why the initiative was taken forward and with what effect.

Reflecting a capacity to engage with various pressing service and workforce concerns, the access to employment programme involved two teams in the NHSE Nursing Directorate: the Public Participation team, seeking greater service user engagement in service delivery, and the Workforce team responsible for the HCSW programme attempting to support Trusts recruit and retain support workers. Also striking was the partnership nature of the programme, with organisations from the voluntary sector bringing their expertise to bear on its different elements. The homelessness charities Pathway and Groundswell were involved, the former playing the lead in recruiting Trusts to the programme, and the latter in generating individual participants with lived experience in the appropriate catchment areas. The Royal Society of Public Health delivered a three-day employability course for the Trusts involved, leading on to individual participants with lived experience applying and being interviewed for HCSW jobs within the respective Trusts.

For the five participating Trusts, drawn from different NHSE regions, the access to employment programme was connected to an HCSW recruitment and retention drive. There was, however, a recognition that the numbers likely to be taken on were going to be small, with the programme’s scope to develop diverse and inclusive workforces more to the fore as a rationale for their involvement:

“We (the Trust) needed to do something around our local community. We all say we want to do stuff to bring local people in and try to address underrepresented groups but actually we’re not that good at doing it.”

Certainly, the access to employment programme went ‘with the grain’ of more inclusive approaches to recruitment already being encouraged nationally through the HCSW Programme: seeking applicants ‘new to care’; removing the ‘care experience’ requirement from person specifications; making ‘reasonable adjustments’ to application and interview processes, for diverse groups. However, the access to employment programme did require bespoke Trust preparation:

  • HCSW job descriptions were reviewed: for example, in one Trust with a Band 3 HCSW workforce, a new one-year Band 2 Trainee HCSW role was introduced specifically for the programme.
  • Internal partnerships between the various functional teams necessarily involved in the processes were developed, between: nursing staff who were working with the HCSWs; human resource management, with their procedural responsibility for recruitment; and education, providing the induction and further training to support those taken on.
  • Appropriate clinical settings for the new recruits were found, and a balance struck between providing the necessary support for those with lived experience while ensuring that they were not stigmatised or presented as a ‘special case’, so diluting their genuine achievement in securing a post.
  • Procedures were developed to generate the information needed for pre-employment checks, often not readily at hand or easily delivered online by those with lived experience of homelessness.

This evaluation report suggests the programme had secured what might be characterised as cautiously positive outcomes, both for the Trusts and for the individual participants with experience of homelessness. As one of the lived experience participants stated:

“I have recommended it (the programme) to other people. I know quite a few people who would go on it.”

The number of such participants attending the three-day employability courses across the Trusts, at 22, was slightly lower than hoped for, and points to the need for Trusts to develop stronger links with community groups who are often able to access marginalised but potentially valuable future sources of labour. However, the conversion rate for those attending the three-day course to job offers was higher than expected: all five Trusts made job offers to a total of 10 individuals, which is close to half of those joining the programme. The caution kicks in with the those offered job only just beginning in employment. Challenges are likely to lie ahead, with questions remaining about the sustainability of their employment. As one Trust interviewee stressed, illustrating this cautious optimism:

“If we can get them and they stay six months that would be brilliant. I’d definitely be interested in doing something and continuing it but before we did that, I’d want to see this cycle through.”

Ian Kessler is Deputy Director of the NIHR Policy Research Unit in Health and Social Care Workforce. He is also Professor of Public Policy and Management at King’s Business School.

This publication

Kessler, I. (2023) Access to Employment in NHS Health Care Support Worker Roles for People with Lived Experience of Homelessness: Programme Evaluation Final Report. London: NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King’s College London.

November 2023 update

The Recruiting people with experience of homelessness toolkit from NHS Employers, which was informed by Ian Kessler’s study, was published 29 November 2023.